1
|
Pierucci UM, Paraboschi I, Mantica G, Costanzo S, Riccio A, Selvaggio GGO, Pelizzo G. Antenatal Determinants of Postnatal Renal Function in Fetal Megacystis: A Systematic Review. Diagnostics (Basel) 2024; 14:756. [PMID: 38611669 PMCID: PMC11012172 DOI: 10.3390/diagnostics14070756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Introduction: To evaluate the clinical usefulness of demographic data, fetal imaging findings and urinary analytes were used for predicting poor postnatal renal function in children with congenital megacystis. Materials and methods: A systematic review was conducted in MEDLINE's electronic database from inception to December 2023 using various combinations of keywords such as "luto" [All Fields] OR "lower urinary tract obstruction" [All Fields] OR "urethral valves" [All Fields] OR "megacystis" [All Fields] OR "urethral atresia" [All Fields] OR "megalourethra" [All Fields] AND "prenatal ultrasound" [All Fields] OR "maternal ultrasound" [All Fields] OR "ob-stetric ultrasound" [All Fields] OR "anhydramnios" [All Fields] OR "oligohydramnios" [All Fields] OR "renal echogenicity" [All Fields] OR "biomarkers" [All Fields] OR "fetal urine" [All Fields] OR "amniotic fluid" [All Fields] OR "beta2 microglobulin" [All Fields] OR "osmolarity" [All Fields] OR "proteome" [All Fields] AND "outcomes" [All Fields] OR "prognosis" [All Fields] OR "staging" [All Fields] OR "prognostic factors" [All Fields] OR "predictors" [All Fields] OR "renal function" [All Fields] OR "kidney function" [All Fields] OR "renal failure" [All Fields]. Two reviewers independently selected the articles in which the accuracy of prenatal imaging findings and fetal urinary analytes were evaluated to predict postnatal renal function. Results: Out of the 727 articles analyzed, 20 met the selection criteria, including 1049 fetuses. Regarding fetal imaging findings, the predictive value of the amniotic fluid was investigated by 15 articles, the renal appearance by 11, bladder findings by 4, and ureteral dilatation by 2. The postnatal renal function showed a statistically significant relationship with the occurrence of oligo- or anhydramnion in four studies, with an abnormal echogenic/cystic renal cortical appearance in three studies. Single articles proved the statistical prognostic value of the amniotic fluid index, the renal parenchymal area, the apparent diffusion coefficient (ADC) measured on fetal diffusion-weighted MRI, and the lower urinary tract obstruction (LUTO) stage (based on bladder volume at referral and gestational age at the appearance of oligo- or anhydramnios). Regarding the predictive value of fetal urinary analytes, sodium and β2-microglobulin were the two most common urinary analytes investigated (n = 10 articles), followed by calcium (n = 6), chloride (n = 5), urinary osmolarity (n = 4), and total protein (n = 3). Phosphorus, glucose, creatinine, and urea were analyzed by two articles, and ammonium, potassium, N-Acetyl-l3-D-glucosaminidase, and microalbumin were investigated by one article. The majority of the studies (n = 8) failed to prove the prognostic value of fetal urinary analytes. However, two studies showed that a favorable urinary biochemistry profile (made up of sodium < 100 mg/dL; calcium < 8 mg/dL; osmolality < 200 mOsm/L; β2-microglobulin < 4 mg/L; total protein < 20 mg/dL) could predict good postnatal renal outcomes with statistical significance and urinary levels of β2-microglobulin were significantly higher in fetuses that developed an impaired renal function in childhood (10.9 ± 5.0 mg/L vs. 1.3 ± 0.2 mg/L, p-value < 0.05). Conclusions: Several demographic data, fetal imaging parameters, and urinary analytes have been shown to play a role in reliably triaging fetuses with megacystis for the risk of adverse postnatal renal outcomes. We believe that this systematic review can help clinicians for counseling parents on the prognoses of their infants and identifying the selected cases eligible for antenatal intervention.
Collapse
Affiliation(s)
- Ugo Maria Pierucci
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | - Irene Paraboschi
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy;
| | - Guglielmo Mantica
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16131 Genova, Italy;
| | - Sara Costanzo
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | - Angela Riccio
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
| | | | - Gloria Pelizzo
- Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.); (A.R.); (G.G.O.S.)
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milan, Italy;
| |
Collapse
|
2
|
Blumenfeld YJ, Sheth KR, Johnson E, Wall JK, Deprest JA, Russo FM, Danzer E. Development and validation of a novel fetal vesico-amniotic shunt, the vortex shunt. Prenat Diagn 2024; 44:158-166. [PMID: 38009470 DOI: 10.1002/pd.6470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023]
Abstract
Fetal lower urinary tract obstruction (LUTO) is a severe malformation associated with an up to 80% mortality risk as well as significant renal and pulmonary morbidity in survivors. Fetal vesico-amniotic shunts (VAS) bypass the bladder obstruction, improve amniotic fluid volume and enhance in-utero pulmonary development. VAS has been shown to reduce respiratory morbidity and mortality in the neonatal period without proven benefit on long-term renal and bladder function. Clinically available shunts are associated with an up to 80% dislodgement rate, leading to repeat invasive procedures which increase fetal and maternal risks. We developed a novel "Vortex" shunt, which incorporates enhanced fixation to reduce dislodgement, a one-way valve to optimize in-utero bladder function, and enhanced sonographic echogenicity that optimizes the accurate deployment. Following the validation of these characteristics in initial benchtop experiments we have moved to feasibility studies in the fetal lamb model. We hope that the Vortex shunt may ultimately facilitate shunt deployment, reduce dislodgement risk, improve neonatal morbidity and mortality, and decrease the significant healthcare expenditures associated with long-term morbidity in LUTO survivors. In this manuscript, we review the natural history of LUTO, the risks and benefits of clinically available fetal shunts, and our development and early validation experiments.
Collapse
Affiliation(s)
- Yair J Blumenfeld
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Kunj R Sheth
- Department of Urology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Johnson
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - James K Wall
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jan A Deprest
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Francesca M Russo
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Enrico Danzer
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
3
|
Adriaenssens M, De Boe V. Congenital lower urinary tract obstruction with spontaneous fetal bladder rupture due to posterior urethral valves: a case report. J Med Case Rep 2023; 17:445. [PMID: 37875965 PMCID: PMC10598892 DOI: 10.1186/s13256-023-04163-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/04/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Congenital lower urinary tract obstruction (LUTO) is a rare but significant condition affecting fetal urinary tract development. LUTO has a range of etiologies, with posterior urethral valves (PUV) being the most common cause. The prenatal diagnosis of LUTO plays a crucial role in recognizing the condition and guiding management decisions. Prenatal ultrasound serves as the primary tool for identifying LUTO, with key findings including megacystis, bladder wall thickening, oligohydramnios, hydronephrosis, and the 'keyhole sign' indicating dilatation of the posterior urethra. We present a case of congenital LUTO with a rare complication of spontaneous fetal bladder rupture and urinary ascites, treated by peritoneo-amniotic shunt placement. CASE PRESENTATION A 27-year-old pregnant Caucasian women was referred at 28 weeks of pregnancy due to the presence of megacystis and bilateral hydronephrosis on routine ultrasound and suspicion of LUTO. Repeat ultrasound at 29 weeks showed significant fetal ascites, oligohydramnios and resolution of megacystis and hydronephrosis, after which diagnosis of spontaneous bladder rupture was made. Despite ascites aspiration and amnio-infusion, there was persistent ascites and oligohydramnios. A peritoneo-amniotic shunt was placed with resolution of ascites and normalization of the amniotic fluid volume. At 35 weeks, relapse of the megacystis was observed with bilateral pyelectasis and oligohydramnios, possibly due to healing of the bladder rupture, after which elective cesarean section was planned. Cystography confirmed spontaneous healing of the bladder rupture and the presence of posterior urethral valves, which were resected in the neonatal period with cold knife incision. Total follow-up of 8 years continued to show positive ultrasonographic results and good renal function, but the child suffers from bladder dysfunction, manifesting as overactive bladder disease. CONCLUSIONS LUTO might lead to important renal dysfunction and pulmonary hypoplasia in case of increasing disease severity. Spontaneous bladder rupture might improve renal prognosis, acting as a pop-off mechanism by decompression of the urinary tract. However, fetal bladder rupture is rare and only few cases have been reported. Prenatal intervention can be considered for moderate or severe LUTO, but the benefit for long-term outcome remains uncertain and further studies are needed.
Collapse
Affiliation(s)
- Max Adriaenssens
- Department of Urology, Universitair Ziekenhuis Brussel, Brussels, Belgium.
| | - Veerle De Boe
- Department of Urology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| |
Collapse
|
4
|
Early 2 nd trimester vesico-amniotic shunt insertion promises a new era of better outcomes for fetuses with isolated severe lower urinary tract obstruction (LUTO). J Pediatr Urol 2022; 18:127-128. [PMID: 35307334 DOI: 10.1016/j.jpurol.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/24/2022]
|
5
|
Sheth KR, Danzer E, Johnson E, Wall JK, Blumenfeld YJ. Development and in-vitro characterization of a novel fetal vesicoamniotic shunt - the Vortex Shunt. Prenat Diagn 2022; 42:164-171. [PMID: 35048376 DOI: 10.1002/pd.6096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To develop and test a novel vesicoamniotic shunt (VAS) to treat fetal lower urinary tract obstruction (LUTO), decrease dislodgement and optimize shunt deployment in-vitro. METHODS VAS design objectives included: 1) robust and atraumatic fixation elements, 2) kink resistant conduit to adjust to fetal movement and growth, 3) one-way pressure valve to facilitate bladder cycling, and 4) echogenic deployment visualization aids. The force to dislodge the novel Vortex shunt was compared with existing commercially available shunts in a bench-top porcine bladder model. Sonographic echogenicity was evaluated with ultrasound-guided deployment, and the shunt valve pressure measured. RESULTS A prototype novel Vortex shunt was developed using braided nitinol "umbrella-type" ends with a kink-resistant stem incorporating an internal one-way valve. The peak force required to dislodge the Vortex shunt was significantly higher than commercially available shunts (p<0.01). Shunt deployment in the bench-top model was easily confirmed with ultrasound guidance and the brisk decompression of the inflated porcine bladder thereafter. In-vitro valve gauge pressure testing mirrored bladder pressures in human LUTO cases. CONCLUSION In-vitro testing shows that the Vortex shunt may improve deployment, sonographic visualization, kink resistance, and dynamic size adjustment. Validation in preclinical animal models are warranted and currently underway. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Kunj R Sheth
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Urology, Division of Pediatric Urology at Stanford University School of Medicine, Stanford, CA, 94305.,Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - Enrico Danzer
- Division on Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, 10065
| | - Eric Johnson
- Department of Bioengineering, Stanford University, Stanford, CA, 94305
| | - James K Wall
- Department of Bioengineering, Stanford University, Stanford, CA, 94305.,Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Surgery, Division of Pediatric Surgery at Stanford University School of Medicine, Stanford, CA, 94305
| | - Yair J Blumenfeld
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine and Obstetrics at Stanford University School of Medicine, Stanford, CA, 94305
| |
Collapse
|
6
|
Katsoufis CP, DeFreitas M, Leuchter J, Seeherunvong W, Chandar J, Abitbol C. Predictors of advanced chronic kidney disease in infancy after definitive vesicoamniotic shunting for congenital lower urinary tract obstruction. Front Pediatr 2022; 10:977717. [PMID: 36313872 PMCID: PMC9614428 DOI: 10.3389/fped.2022.977717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Severe congenital lower urinary tract obstruction (cLUTO) is associated with poor postnatal outcomes, including chronic and end stage kidney disease, and high mortality. Studies of the impact of fetal intervention through vesicoamniotic shunting are marred by a device malfunction rate of up to 60%. In this study, we delineate the postnatal course and infant kidney function following definitive urinary diversion in utero. MATERIALS AND METHODS This is a retrospective, single-center cohort study of 16 male infants who survived the fetal intervention to birth, from 2010 to 2014 at a single center. All had patent shunts in place at birth. Perinatal and biochemical characteristics were collected with patients followed for one year, or until demise, with serial measures of serum creatinine (SCr) and serum cystatin C (CysC). RESULTS Of the 16 males, 81% were non-white (38% black, 43% Hispanic). Shunts were placed at a median of 20 weeks (IQR 19,23) gestation, with median fetal bladder volume of 39 cm3 (IQR 9.9,65). All neonates were born preterm [median 34 weeks (IQR 31,35)] and the majority with low birth weight [median 2340 grams (1,895, 2,600)]. 63% required positive pressure ventilation. Advanced chronic kidney disease stage 4-5 at 1 year of age was predicted by neonatal characteristics: peak SCr ≥2 mg/dl, time to peak SCr > 6 days, discharge SCr ≥1.0 mg/dl, CysC ≥2.5 mg/l, urine protein:creatinine ≥4.8 mg/mg, urine microalbumin:creatinine ≥2.2 mg/mg. In infancy, a nadir SCr ≥0.5 mg/dl occurring before 160 days (5.3 months) of age was also predictive of advanced chronic kidney disease stage 4-5 at 1 year. Three patients died in the neonatal period, with 1 receiving kidney replacement therapy (KRT). Three additional patients required KRT before 12 months of age. CONCLUSIONS Even with definitive vesicoamniotic shunting for cLUTO, postnatal morbidity and mortality remain high, emphasizing the role of renal dysplasia, in spite of urinary diversion, in postnatal kidney dysfunction. Neonatal and infant biochemical parameters exhibit distinct trends that offer families and physicians a better understanding of the prognosis of childhood kidney function.
Collapse
Affiliation(s)
- Chryso Pefkaros Katsoufis
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| | - Marissa DeFreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| | - Jessica Leuchter
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| | - Wacharee Seeherunvong
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| | - Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| | - Carolyn Abitbol
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, United States
| |
Collapse
|
7
|
Farrugia MK, Kilby MD. Therapeutic intervention for fetal lower urinary tract obstruction: Current evidence and future strategies. J Pediatr Urol 2021; 17:193-199. [PMID: 33583743 DOI: 10.1016/j.jpurol.2021.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/30/2020] [Accepted: 01/24/2021] [Indexed: 12/11/2022]
Abstract
In-utero vesica-amniotic shunting for fetal lower urinary obstruction (LUTO) is known to improve perinatal survival. More recently, studies including centres performing fetal cystoscopy, have suggested benefit on longer-term survival and renal outcome - within the limitations of small numbers and limited follow-up. These interventions carry significant risk, and therefore patient selection, and optimal timing, are key. The aim of this article is to explore ways of improving the accuracy of prenatal diagnosis, and of identifying risk factors for fetal and postnatal renal failure. The next step is that of using established staging and classification systems to select the patient group that may benefit from intervention, based on published outcomes. Several factors come into play when selecting the timing of intervention, especially if the aim is that of renal, and not only pulmonary, preservation. Lastly, current technologies and their shortfalls are discussed.
Collapse
Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea & Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK; Imperial College London, Exhibition Road, London SW7 2AZ, UK.
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Birmingham, B15 2TG, UK; College of Medical & Dental Sciences, University of Birmingham, B15 2TT, UK
| |
Collapse
|
8
|
Selection of candidates for foetal intervention in congenital lower urinary tract obstruction. Curr Opin Obstet Gynecol 2021; 33:123-128. [PMID: 33620890 DOI: 10.1097/gco.0000000000000693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Congenital lower urinary tract obstruction (LUTO) is a rare group of conditions characterized by high perinatal morbidity and mortality if associated with oligohydramnios or anhydramnios in early pregnancy. Although foetal intervention has the potential to improve perinatal survival in a select group of foetuses with LUTO, the actual selection of those candidates most likely to benefit from intervention remains challenging. RECENT FINDINGS Foetuses with LUTO who are potential candidates for prenatal intervention should undergo detailed multidisciplinary evaluation to ensure proper assessment and counselling. Using a combination of multiple ultrasound-based renal parameters, including measurement of foetal bladder volumes before and after vesicocentesis and kidney size and morphology, combined with repeated foetal urine biochemistry may allow for better selection than any single test. SUMMARY Foetal intervention should be offered to women carrying a foetus with LUTO only after appropriate evaluation and counselling. A combined approach utilizing ultrasound and biochemical measurements of foetal renal function appears best. Research focusing on the development of more accurate markers is needed.
Collapse
|
9
|
Jank M, Stein R, Younsi N. Postnatal Management in Congenital Lower Urinary Tract Obstruction With and Without Prenatal Vesicoamniotic Shunt. Front Pediatr 2021; 9:635950. [PMID: 33937148 PMCID: PMC8079780 DOI: 10.3389/fped.2021.635950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/22/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose: Congenital lower urinary tract obstruction (cLUTO) includes a heterogeneous group of conditions caused by a functional or mechanical outlet obstruction. Early vesicoamniotic shunting (VAS) possibly reduces the burden of renal impairment. Postpartum, pediatric urologists are confronted with neonates who have a shunt in place and a potentially impassable urethra with a narrow caliber. Early management of these patients can be challenging. Here, we would like to share the approach we have developed over time. Materials and Methods: We conducted a single-center retrospective analysis from 2016 to 2020 and included all patients diagnosed with cLUTO. Data focusing on time point and type of intervention was collected. Furthermore, patients with temporary diversion via a percutaneous VAS were selected for a more detailed review. Results: In total, 71 cases of cLUTO were identified during the study period. Within this group, 31 neonates received postnatal management and surgical intervention in our center. VAS was performed in 55% of these cases (N = 17). The postnatal treatment varied between transurethral or suprapubic catheterization and early Blocksom vesicostomy. In five infants with VAS, the urinary drainage was secured through the existing VAS by inserting a gastric tube (N = 1) or a 4.8 Fr JJ-stent (N = 4). To our knowledge, this is the first report of a stent-in-stent scheme, which can remain indwelling until the definite treatment. Conclusion: Having a secure urine drainage through a VAS allows the often premature infant to grow until definite surgery can be performed. This avoids placing a vesicostomy, which requires anesthesia.
Collapse
Affiliation(s)
- Marietta Jank
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany.,Department of Pediatric Surgery, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Raimund Stein
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| | - Nina Younsi
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
10
|
Abstract
Fetal lower urinary tract obstruction (LUTO) is classically based on prenatal ultrasound identification of a dilated/ thick-walled bladder, bilateral hydronephrosis, dilated ureters and a dilated posterior urethra (also known as the "keyhole sign") in a male fetus. Although the most common underlying diagnosis is posterior urethral valves, the prenatal appearance may be similar with urethral atresia or stenosis, the Prune-Belly Syndrome, or even a cloacal anomaly in a female. These conditions form part of the Congenital Anomalies of Kidney and Urinary Tract (CAKUT) spectrum, which is the commonest cause of end-stage renal disease in children. Although it is difficult to predict postnatal renal function from the prenatal appearance, studies have recently identified predictive features (based on ultrasound findings and fetal biochemistry), and established staging systems to assist with counselling, and, where indicated, patient selection for in-utero intervention. Current in-utero therapy includes amnio-infusion, vesico-amniotic shunting, and fetal cystoscopy with valve ablation or urethral stenting. Postnatal survival and renal functional outcomes, complications and management uncertainties are described, highlighting areas of future development.
Collapse
Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea and Westminster and Imperial College Hospitals, United Kingdom of Great Britain and Northern Ireland; Imperial College London, United Kingdom of Great Britain and Northern Ireland.
| |
Collapse
|
11
|
Katsoufis CP. Clinical predictors of chronic kidney disease in congenital lower urinary tract obstruction. Pediatr Nephrol 2020; 35:1193-1201. [PMID: 31197474 DOI: 10.1007/s00467-019-04280-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/07/2019] [Accepted: 05/23/2019] [Indexed: 12/28/2022]
Abstract
Congenital lower urinary tract obstruction is associated with oligohydramnios and significant perinatal mortality and long-term chronic kidney disease. The counseling of families facing this diagnosis, especially when prenatal intervention is proposed, is fraught with ambiguity. This review aims to equip the provider with the current evidence behind the conventional and novel biomarkers predictive of chronic kidney disease. The relevant clinical predictors are categorized by when they are identified, antenatally or postnatally, and as either anatomic or chemical. They are considered for their prognostic value and the challenges in obtaining them, specifically the risk to the fetus in the case of prenatal biomarkers. Serum creatinine in infancy is the traditional chemical biomarker of kidney function and continues to be a consistent predictor of future serum creatinine. β-2 microglobulin may provide earlier information regarding fetal glomerular and tubular function and is also predictive of long-term serum creatinine. Renal parenchymal area is an anatomic surrogate of nephron mass that is used in both prenatal and postnatal settings. Understanding the anatomic and chemical biomarkers is essential for future refinement of the staging algorithm used to distinguish which patients may benefit from early in utero intervention.
Collapse
Affiliation(s)
- Chryso Pefkaros Katsoufis
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, P.O. Box 016960 (M-714), Miami, FL, 33101, USA.
| |
Collapse
|
12
|
Abstract
Fetal intervention has progressed in the past two decades from experimental proof-of-concept to practice-adopted, life saving interventions in human fetuses with congenital anomalies. This progress is informed by advances in innovative research, prenatal diagnosis, and fetal surgical techniques. Invasive open hysterotomy, associated with notable maternal-fetal risks, is steadily replaced by less invasive fetoscopic alternatives. A better understanding of the natural history and pathophysiology of congenital diseases has advanced the prenatal regenerative paradigm. By altering the natural course of disease through regrowth or redevelopment of malformed fetal organs, prenatal regenerative medicine has transformed maternal-fetal care. This review discusses the uses of regenerative medicine in the prenatal diagnosis and management of three congenital diseases: congenital diaphragmatic hernia, lower urinary tract obstruction, and spina bifida.
Collapse
Affiliation(s)
- Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Center for Regenerative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
13
|
Perlman S, Borovitz Y, Ben-Meir D, Hazan Y, Nagar R, Bardin R, Brusilov M, Dekel B, Achiron R, Gilboa Y. Prenatal diagnosis and postnatal outcome of anterior urethral anomalies. Prenat Diagn 2019; 40:191-196. [PMID: 31654578 DOI: 10.1002/pd.5582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/24/2019] [Accepted: 09/15/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Anterior urethral anomalies (AUA) which present as anterior urethral valve, stenosis or atresia, are a rare cause for congenital urinary tract obstruction. We present our AUA prenatal diagnosis case series. METHODS Fetuses presenting with prenatal findings suggestive for AUA according to postnatal reported clinical and imaging signs (urinary tract dilatation, dilated bladder, enlarged edematous fetal penis, dilatation of the fetal urethra and diverticula) were followed prospectively. RESULTS Six fetuses were diagnosed with AUA. Diagnosis was confirmed upon examination of the neonate or the abortus. All cases presented with variable degrees of urinary tract dilatation. Four fetuses who presented with additional congenital anomalies of the kidneys and urinary tract (CAKUT) developed intra-uterine or early postnatal renal failure, while two isolated AUA cases have a normal renal outcome. CONCLUSIONS AUA is a rare diagnosis. However, high index of suspicion and careful sonographic assessment of the male fetal urethra in cases referred for urinary tract dilatation may enable appropriate parent counseling, optimal prenatal surveillance and timed postnatal urological intervention. As in other lower urinary tract obstructions, future renal function seems to correlate with associated CAKUT, therefore close follow up throughout pregnancy and meticulous sonographic assessment is recommended.
Collapse
Affiliation(s)
- Sharon Perlman
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Borovitz
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Schneider Children's Medical Center, Nephrology Institute, Petach Tikva, Israel
| | - David Ben-Meir
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Urology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Yenon Hazan
- Ultrasound Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel.,Hadassah and the Hebrew University Medical School, Jerusalem, Israel
| | - Ran Nagar
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ron Bardin
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Ultrasound Unit, The Helen Schneider Women's Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Michael Brusilov
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Ultrasound Unit, Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Benjamin Dekel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Division of Pediatric Nephrology, Edmond and Lily Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Pediatric Stem Cell Research Institute, Edmond and Lily Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Reuven Achiron
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yinon Gilboa
- Prenatal Diagnostic Unit, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
14
|
Nassr AA, Shamshirsaz AA, Erfani H, Espinoza J, Sanz Cortes M, Koh CJ, Roth DR, Angelo JR, Mandy GT, Braun MC, Ruano R, Belfort MA. Outcome of fetuses with lower urinary tract obstruction and normal amniotic fluid volume in second trimester of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:500-505. [PMID: 30977189 DOI: 10.1002/uog.20288] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/15/2019] [Accepted: 04/05/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Congenital lower urinary tract obstruction (LUTO) is a rare condition with high perinatal mortality and morbidity when associated with severe oligohydramnios or anhydramnios in the second trimester of pregnancy. Severe pulmonary hypoplasia and end-stage renal disease are the underlying causes of poor neonatal outcome in these cases. However, little is known about the subset of fetal LUTO that is associated with a normal volume of amniotic fluid at midgestation. The objective of the current study was to describe the natural history, underlying causes, survival and postnatal renal function outcomes in pregnancies with fetal LUTO and normal amniotic fluid volume during the second trimester of pregnancy. METHODS This was a retrospective study of all pregnancies with fetal LUTO and normal amniotic fluid volume in the second trimester that received prenatal and postnatal care at our quaternary care institution between 2013 and 2017. Data on demographic characteristics, fetal interventions, perinatal survival, need for neonatal respiratory support, postnatal renal function and need for dialysis at the age of 1 and 24 months were analyzed. RESULTS Of the 18 fetuses that met the study criteria, 17 (94.4%) survived the perinatal period. Eleven (61.1%) pregnancies developed oligohydramnios in the third trimester, six of which were eligible for and underwent fetal intervention with vesicoamniotic shunt placement, which was performed successfully in all six cases. Two (11.1%) neonates required respiratory support owing to pulmonary hypoplasia. At the age of 2 years, 14 children had follow-up information available, two (14.3%) of whom had normal renal function, eight (57.1%) had developed some degree of chronic kidney disease (Stage 1-4) and four (28.6%) had developed end-stage renal disease (ESRD), including two who had already manifested ESRD in the neonatal period. CONCLUSIONS Most fetuses diagnosed prenatally with LUTO that is associated with a normal volume of amniotic fluid at midgestation will have a favorable outcome in terms of perinatal survival and few will need long-term respiratory support. However, these children are still at increased risk for chronic renal disease, ESRD and need for renal replacement therapy. Larger multicenter studies are needed to characterize the prenatal factors associated with postnatal renal function, and to investigate the role of fetal intervention in the group of fetuses that present with late-onset oligohydramnios and evidence of preserved fetal renal function. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - C J Koh
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - D R Roth
- Division of Pediatric Urology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J R Angelo
- Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - G T Mandy
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M C Braun
- Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| |
Collapse
|
15
|
Vinit N, Gueneuc A, Bessières B, Dreux S, Heidet L, Salomon R, Lapillonne A, De Bernardis G, Salomon LJ, Stirnemann JJ, Blanc T, Ville Y. Fetal Cystoscopy and Vesicoamniotic Shunting in Lower Urinary Tract Obstruction: Long-Term Outcome and Current Technical Limitations. Fetal Diagn Ther 2019; 47:74-83. [PMID: 31401627 DOI: 10.1159/000500569] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In utero therapeutic approaches for lower urinary tract obstruction (LUTO) have been developed to salvage the fetal kidney function. OBJECTIVE The aim of this work was to report the long-term survival, nephrological, and urological outcome of children treated prenatally for LUTO using operative fetal cystoscopy (FC) and vesicoamniotic shunting (VAS) or both. METHODS A retrospective study of 48 procedures (23 FC, 25 VAS) was performed on 33 patients (between 2008 and 2018). Reviewed data included prenatal management and clinical follow-up by a pediatric nephrologist and a pediatric urologist. Both intention-to-treat and per-protocol analyses were conducted. RESULTS The median follow-up was 3.6 years (0.5-7) for FC and 2.5 years (1.1-5.1) for VAS. There was no difference between FC and VAS in terms of survival (92 vs. 83%, p = 1), complication rate (74 vs. 92%, p = 0.88), or chronic kidney disease (58 vs. 50%, p = 1). The number of procedures was higher in the VAS group: 1.7 (1-3) versus 1.1 (1-2), p = 0.01. With a 30% rate of technical failure, FC added diagnostic value in 3 out of 21 cases. CONCLUSIONS No difference was found between FC and VAS regarding survival, long-term kidney function, or urological outcome. Despite overly optimistic reports on FC, it lacks reproducibility due to posterior-urethra inadequate visualization and inappropriate instrumentation.
Collapse
Affiliation(s)
- Nicolas Vinit
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Alexandra Gueneuc
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Bettina Bessières
- Department of Histology, Embryology and Cytogenetics, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sophie Dreux
- Department of Biochemistry-Hormonology, Robert Debré Hospital, APHP, Paris, France
| | - Laurence Heidet
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Rémi Salomon
- Department of Pediatric Nephrology, Necker-Enfants Malades Hospital, APHP, Paris, France.,Paris Descartes University, Paris, France
| | - Alexandre Lapillonne
- Department of Neonatology, Necker-Enfants Malades, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Gaston De Bernardis
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Julien J Stirnemann
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France
| | - Thomas Blanc
- Department of Pediatric Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France.,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France.,INSERM U1151-CNRS UMR 8253, Paris Descartes University, Necker-Enfants Maladies Institute, Necker-Enfants Malades Hospital, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France, .,EA 7328-PACT, Paris Descartes University, Sorbonne Paris Cité, Imagine Institute, Paris, France,
| |
Collapse
|
16
|
Fontanella F, van Scheltema PNA, Duin L, Cohen-Overbeek TE, Pajkrt E, Bekker MN, Willekes C, Oepkes D, Bilardo CM. Antenatal staging of congenital lower urinary tract obstruction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:520-524. [PMID: 29978555 DOI: 10.1002/uog.19172] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/10/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- F Fontanella
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - L Duin
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T E Cohen-Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M N Bekker
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Willekes
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center, Grow School for Oncology and Medical Biology, Maastricht, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C M Bilardo
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics, Gynecology and Prenatal Diagnosis, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
17
|
Abstract
Fetal surgery is an established but still rapidly evolving specialty, born from the rationale that destructive embryologic processes, recognized early in gestation, can be curtailed by prenatal correction. As more and more centers begin offering fetal interventions, quality of care must be verified through transparency about clinical capabilities and resources. Level designations should be assigned based on capability, as in trauma and neonatal ICU centers for excellence, and volume requirements must be set for fetal surgery certification. Regionalization of this specialty care may be required to optimize outcomes.
Collapse
Affiliation(s)
- Heron D Baumgarten
- Department of Surgery, Abramson Research Center, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA
| | - Alan W Flake
- Department of Surgery, Abramson Research Center, Room 1116B, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA.
| |
Collapse
|
18
|
Cheung KW, Morris RK, Kilby MD. Congenital urinary tract obstruction. Best Pract Res Clin Obstet Gynaecol 2019; 58:78-92. [PMID: 30819578 DOI: 10.1016/j.bpobgyn.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/01/2019] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
Congenital bladder neck obstruction (or lower urinary tract obstruction [LUTO]) describes a heterogeneous group of congenital anomalies presenting with similar prenatal ultrasonographic findings of dilated posterior urethra, megacystis, hydronephrosis, oligohydramnios and often with associated renal dysplasia. Untreated LUTO has high rate of perinatal morbidity and mortality from associated pulmonary hypoplasia and early-onset renal failure in infancy. Ultrasonographic features and prospective fetal urinalysis may help in predicting the overall prognosis of congenital LUTO. Currently, fetal vesicoamniotic shunt (of various designs), and fetal cystoscopy and fulguration of the obstruction are potential prenatal interventions. Retrospective and prospective cohort studies and a relatively small randomized controlled trial have demonstrated these treatments may possibly improve perinatal survival. Despite this, concerns remain as to the high rates of renal impairment observed in paediatric survivors. A clinical prospective scoring/staging system may improve prenatal diagnostic criteria and case selection for fetal therapy.
Collapse
Affiliation(s)
- Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China; The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.
| | - Rachel Katie Morris
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Mark David Kilby
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK; The Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|